Provider Demographics
NPI:1124057344
Name:MEDICAL PARK ORTHOPAEDIC CLINIC
Entity type:Organization
Organization Name:MEDICAL PARK ORTHOPAEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-454-4561
Mailing Address - Street 1:1301 W 38TH ST
Mailing Address - Street 2:STE. 102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1000
Mailing Address - Country:US
Mailing Address - Phone:512-454-4561
Mailing Address - Fax:512-467-2906
Practice Address - Street 1:1301 W 38TH ST
Practice Address - Street 2:STE. 102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1000
Practice Address - Country:US
Practice Address - Phone:512-454-4561
Practice Address - Fax:512-467-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0587470001OtherPALMETTO GBA
TXCC8254OtherRAILROAD MEDICARE
TX00J744OtherBCBS
TX0587470001OtherPALMETTO GBA